Provider Demographics
NPI:1013338169
Name:AN, ELIZABETH (RPH)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:AN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:TAPPAN
Mailing Address - State:NY
Mailing Address - Zip Code:10983-1000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:MONTEFIORE PHARMACY
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-4934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046014183500000X
NJ26RI02060100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RI02060100OtherPHARMACY LICENSE
NY046014OtherPHARMACY LICENSE